Transcript for:
NICU Speech-Language Pathology Role

Kristen West: So this is our lecture about slps and our role in the Nicu. So we'll kind of get started with an overview here slps in the Nicu. Our role in the Nicu is really not just about feeding and swallowing, so we will talk a lot about the role of us in feeding and swallowing. But I want to take a minute to talk about us as the role in the Nicu in general, not just a heavy focus on dysphagia and feeding. Kristen West: And we really need to think about how we are part of that interdisciplinary team. You know the nurses, the physicians, the respiratory therapist. You know a lot of the medical providers are there looking at. Kristen West: providing support and addressing medical conditions, and we may be addressing the feeding and swallowing concerns of the infants that are related to their medical condition. But we're also there to look at these infants through a developmental lens and a protective lens where we're looking at, how do we help safeguard their development? How do we help limit the impact of being born prematurely or having medical comorbidities or conditions that Kristen West: co-occur with prematurity or a result of prematurity. And how do we make sure that we, you know, do everything we can in the environment and in what we're exposing these infants to to lessen the impact of that prematurity or of those medical conditions on their overall development, speech, language, cognition, play feeding, swallowing. You know, negatively. Kristen West: and we're gonna kind of talk a little bit more about an overview of factors specific to the Nicu setting that Slp should understand. Kristen West: So the Nicu is an icu for neonates, including premature infants. So what is prematurity? If we kind of just think about it in these terms we have extreme prematurity, which is a baby born before 25 weeks. 40 weeks is a full term. Pregnancy, you know. That's the goal, we think, between 38 and 40 is ideal. So extremely preterm babies are born before 25 weeks. Kristen West: Very preterm. Infants are born 25 to 32 weeks, moderately preterm babies are born between 32, and 34 weeks, and late preterm babies are born between 34, and 36 weeks. Kristen West: You also will see through your readings through the Asha readings as well that there will be other terms looking at infants by birth weight. So do pay attention to those I'm just going to highlight the ones that are related to an infant's gestational age at birth, and how that Kristen West: results in things like extremely, very moderately or late preterm. 37 weeks is considered term, but because, you know, dating a pregnancy and an infant's gestational age is not an exact science. Sometimes our 37 weekers can present more like a late preterm infant. So we just always want to be aware of that. Kristen West: Nicu by the numbers. So this could, you know, is looking to be updated relatively soon. But, generally speaking, we see premature birth or birth before 37 weeks of pregnancy, and its complications are the number one cause of death of babies. Kristen West: There's about 380,000 babies born prematurely each year. It's almost 10% on the preterm birth rate. So it's like one in every 10. Babies are born before 37 weeks, and we know that preterm infants are more at risk for motor impairments, sensory impairments, cognitive deficits and behavioral and mental health disorders. Kristen West: So you're going to read a little bit about this. But there, I want to just draw attention to the Asha knowledge and skills for Slp in the Nicu that you'll be taking a deeper dive into. Asha says that when slps are working in the Nicu they have to understand normal embryological perinatal and postnatal infant development. So you know, we spent some of the time looking at some of those prerequisite knowledge already here in this course to date. Kristen West: We also have to have an understanding of current research in neurobiology, physiology, and genetics, as they relate to infant behavior. You will be reading during this module a chapter that is looking at the medical Co. Morbidities, or the medical conditions that can Co occur with prematurity to help you understand that when we think about some of those conditions, and some of them may be genetically weight. Kristen West: genetically related, and causing that prematurity, other things are physiological changes and things like lungs, or the digestive system that are a direct result of prematurity. So you'll read more on those this week as well. Kristen West: Slps in the Nicu also need to know atypical infant development which includes theories and research findings, risk factors in prenatal and perinatal development, etiologies and medical conditions. And so we talked a little bit about that again in our embryological development lectures about normal and then atypical. So we're already kind of hitting some of these Kristen West: points in this class. We also have to understand Family center practices including the impact of the Nicu experience on family dynamics and their function understanding the family systems, parent infant interactions. How to empower parents use coaching principles that you know, have been talked about or will be talked about in the birth of 5 class and then you've also seen in some of your other classes, I'm sure talks about in clinical classes about working with families. Kristen West: Also, there is an importance of talking about interprofessional practice. How do we work as part of that larger medical team, as we know from the Pfd diagnosis kids with medical conditions. They have medical, they have nutritional. They have psychosocial, and they have feeding skill needs. And so you know, in the medical domain we have, you know, physicians, nurses, neonatologists, gastroenterologists, ents. Kristen West: That we're working with in the you know, feeding skill. We are still working with occupational therapists. We might even be working with physical therapists if there's something related to their motor skills. Kristen West: So we have to have that within the therapy disciplines. Professional practice also working with people like our registered dietitians and other professionals. Kristen West: as well. So it's really an interprofessional practice. Setting for us when we're in the Nicu. So things to know about. We also just need to understand as slps those team based processes. So things that we'll talk about and that'll come up in the medical slp class. But things like medical rounds. What do medical rounds mean? How does that medical rounds impact the Kristen West: the family, the child, you know, the infant that's there. How do we work together as a team to counterbalance what we're looking at from a developmental and feeding lens. But what the baby's, you know, respiratory, gi neurological needs and capabilities are. And talking about kind of you know we might be. We're looking at feeding through a lens of positivity and success. And we don't want to push volume because we want them to develop those. Kristen West: But the physicians are looking at, you know, volume as an indicator of growth and what they need to grow and sustain. So we have to kind of understand those different perspectives that are coming to the table when we're talking about feeding and swallowing in the Nicu Kristen West: slps in the Nicu also have to have specialized knowledge in developmentally supportive care. So we'll talk about synactive theory, behavioral state organization, you know, different care models that we're looking at in the Nicu in a little bit as well, and understanding those medical complications, staffing patterns in the nicu ecology and parent of the Nicu and parenting in the Nicu. So again, you'll get a lot of this through your reading, but we're going to touch on some of this in the lecture as well. Kristen West: So let's talk about our role in the Nicu as an slp Kristen West: slps are a large are one slice of a larger therapy in the Nicu that's called neonatal therapy. Kristen West: We are the specialists in infant communication. In addition to the specialist in infant feeding. So we are really thinking about reading that baby's behavior. How are their vital signs? How is their oxygen level? How is their heart rate. What does their respiratory rate look like? What is the coloring of that baby? That's all at its basis, although, you know it is kind of a cue about how their body Kristen West: is functioning, it at its best, definition is communication. And so what we talk about in the Nicu when we work with infants is being infant, driven, meaning, we are like really responding to the communication of the infant. If I'm holding them, and they, you know, turn into a wet noodle, or they have really high tone, or they look stressed, and they have a high heart rate and a low heart rate. And they're, you know, really red, and then they look a little dusky or a little pale. Kristen West: Those are all things that tell me. They're not tolerating what I'm doing. That's communication. So I need to change my actions to help support that baby while they're still preterm and developing Kristen West: so we wanna think about that. We think about our role in feeding. But we can also think about being part of that team. So one of our roles is to help protect Kristen West: the establishment of neural pathways that are normal or expected development. So in normal infancy touches associated with positive feelings. But in the Nicu these infants are getting poked and prodded and getting heel sticks like they stick their heel to be able to like, get blood draws. They might be getting different procedures. Bass in the Nicu are not always peasant for babies. Babies don't always like bass. Kristen West: and so how do we support that team during those kind of situations to offset any what we might call negative touch or negative experiences for the infant, and counterbalance them with something positive, because that's going to help establish those neuro pathways for positivity and touch, or at least counterbalance, any negative touch with positive touch. So we don't get things like aversion to touch or aversion to things around our mouth as an example. Kristen West: So that's kind of what our role can be during those kind of procedures to help think about, you know, how do we establish? Kristen West: you know, neural pathways. And how do we get like neurological pruning and development? That is, you know, going to emulate like positive or mimic. You know what should be happening. The phrase neurons that fire together wire together. So thinking about if every time that you know sensory neurons are firing, it's coming with negative touch. Then we're going to like, reinforce that pathway for pain. And so we want to Kristen West: make sure that's not the pathway that's getting the most input we want to make sure it's counterbalanced with a lot of positive input. So we don't have that happening. Kristen West: We really want to help be that communication specialist. We're going to talk about infant stress cues a lot. And so when we get there, think about this. And how do we help the team respond to those stress cues, read them, and when we can, you know, sometimes in a medical procedure, they can't avoid it. But then, how do we counterbalance that, or be able to respond and shift gears when we can. When we see these stress cues in our infant. Kristen West: really, our goal is to normalize their development, help them conserve energy, facilitate organization. So like just them being calm with a, you know, stable heart rate, stable respiration, good color, you know. Good alertness. If that's developmentally appropriate and then recognize what is stressing out these infants, what does cause them stress, and what allows them to calm? Or how do we teach them to calm and get them to a point when they're closer to term, they learn how to self, soothe or self consult. Kristen West: The Nicu is an interprofessional team. It does take a village. So there's a primary team and our specialized consultants that are all working together. But we should keep that parent at the center. So in the Nicu you could have the physicians like the neonatologist, you could have those advanced practice registered nurses, physician assistants, bedside nurses, respiratory, therapists, ptot speech. Kristen West: music, therapist, child life, radiology, technicians, nutritionists, you know, or a registered dietitian social worker. And then you have specialists that come in as well. Right? So there's an airway concern. You might have otolaryngologists. You have the audiologist coming in and screening for hearing and checking their hearing because there's a lot of drugs that are used to help sustain life in the Nicu that can be ototoxic meaning. It can cause hearing loss. Kristen West: So we need to think about that. We can also have you know, specialists in lung or breathing. So those pulmonologists or neurologists because there is, you know, the younger. The baby is born gestationally age. So they're extremely preterm. For example, there's a higher risk of interventricular hemorrhage, which is a Kristen West: bleeding in their brain which is related to their prematurity, depending on how severe that bleed is, it can cause increased risk of cerebral palsy and other neurological and developmental challenges down the road. Kristen West: So it's very common to be working with a neurologist, because that is something that we do monitor for and see in our very sick infants in the Nicu. Some of these babies may have trouble with hydrocephalus or their ventricles in their brain that are responsible for circulating that cerebrospinal fluid. You know they may not be able to do that appropriately, and if that doesn't happen, they can end up with a condition called hydrocephalus, and they might need a shunt. Kristen West: And so neurosurgeons are something that we might see as part of a nicu infant specialized care team. We can have neonatal surgeons. So any sort of you know, if a child has an instance of necrotizing enterocolitis, for example, which is part of the Gi system. You know those tissues dying because of, you know, something in that digestive process that's happening because they're born too soon. Kristen West: They might require, then surgery to cut out part of that bowel. And so we can have those neonatal surgeons. There is a higher incidence of heart conditions or heart conditions that are related to prematurity, that if they don't resolve on their own, could recall a Ct. Surgeon or a cardiothoracic surgeon, but they're normally going to be monitored by a cardiologist before that. Kristen West: And again, gastroenterologists are common consultants in the nicu as well developmental pediatricians, and so much more. I do want to take a note here to kind of say, although in the Nicu a lot of what we're going to be talking about is preterm infants. You have to recognize that in a nicu you also will have very sick Kristen West: term infants as well. So if they have like multiple medical conditions, and they are born at term. But they still have a lot of health needs. Those infants are also going to end up in our Nicu. So it's not just premature infants. But there's also children with significant genetic conditions or other medical comorbidities that are going to negatively impact their ability to sustain life whenever they are born. Kristen West: They're born at term, and so what we will see is those infants will end up in the Nicu as well. So just be aware of that Kristen West: at the middle of all of that. Who you know, the primary team, the specialized consultants, really is the parent that we are trying to help, support, and use family-centered care to help enhance their bonding with their infant, provide counseling help, enhance their confidence and their ability to care for support, understand the actions of their infant, and also recognizing these parents, have gone through a lot of trauma, and so those families will need some family Kristen West: centered support. It's not just, you know, the infant is definitely there. But we have to think about social work. Psychologists, you know, other sort of financial support emotional support. That the family may require as well, so they can be present and help care for their infant during the Nicu, because a lot of times. A nicu stay is not an expected thing. Kristen West: it can be sometimes for term infants that have been diagnosed prenatally, and they will prepare for that experience, but a lot of times for preterm infants. That kind of preterm birth was not expected. And so there's a lot of challenges around navigating that, and we want to make sure families can be present for their infants as much as possible. So we try to work collaboratively as a team to help support that parent as well. Kristen West: So interprofessional practice. Or Ipp occurs when there's multiple service providers from different professional backgrounds provide comprehensive healthcare educational services. By working with individuals, or in this case the infant and their families. Kristen West: in addition to the caregivers and their community, to deliver the highest quality of care. This is how we set infants up for success in the Nicu. But also we have to think about when these Nicu infants and families leave the Nicu. If that's where we're working, how do we set them up in that next care, setting so outpatient early intervention and kind of hand, the baton, to make sure they continue on with these services and supports when they discharge home. Kristen West: So let's talk a little bit about approach to care in the Nicu. Neuroprotective care is the goal of neonatal therapy or the goal of us as slps working in the nicu. Kristen West: we define neonatal therapy and neuroprotective care and neonatal therapy specifically as strategies that are capable of preventing neuronal cell death. So the cell death of the neurons. So we do know that during periods of apnea, that is, cysteine or hypoxia. There is potential that neurons are dying right? They aren't getting the oxygenation that they're needed. Kristen West: And these apneic and hypoxic events can happen in the Nicu, because their respiratory system is more underdeveloped, they end up being on the vent, they end up being on immuno nasal cannulas, and it's tried to be limited as much as possible, but they do happen. And so we are trying to think of what are we doing that is going to help protect the brain and the overall body development of this infant. In addition to, you know, those life sustaining measures that happen in the Nicu. Kristen West: So we think about this is, how do I help support that baby's developing brain or facilitate recovery? Right? If they've had like, maybe they've had a hypoxic event or anoxic event? Or maybe they've had an interventricular hemorrhage which has caused death of those neurons right? Because they've had some sort of injury from a brain bleed. How do I think about ways in therapy Kristen West: and the things that I'm doing with the infant to help support their ability to recover or make new pathways or strengthen their pathways right? Because they're born preterm. They're not quite even supposed to be here. How do we limit the impact of those things on their development? We want to think about. How can we help, you know, establish new neural pathways for functionality is what it's called. Kristen West: We also want them to be able to make sense of all of the input they're getting. There's lights, there smells, there's signs. There's sounds. There's touch that they should still be in an intrauterine environment. If they're born preterm right? And they are not. Their body's not really ready for processing all that information yet, but they have to. So how do we help facilitate their ability to tolerate that Kristen West: even for a term infant that's sick. They're getting a lot of exposure and touch and taste and smells and things that are atypical. They're not. You know what their term well, infant counterparts are getting. And so how do we Kristen West: kind of again counterbalance those experiences to also help normalize or make more positive experiences for these infants, because that is essentially establishing neuro pathways because we have neural pathways that need to be reinforced. So they developed. And then there's pathways. They get pruned or they get eliminated right? So if we get a lot of input for say, negative touch, you know, negative association, pain, discomfort with eating, with things in and around my mouth, and that's predominantly reinforced pathway. Kristen West: Then we think about how is that going to alter their experience with eating. Kristen West: and we can also have infants that have had, you know, some sort of brain damage in the you know, by having, say, an interventricular hemorrhage. We know that some of swallowing it does have cortical, or that higher level brain involvement. And so any sort of brain injury could negatively impact their feeding and swallowing safety and be compounded by their neuro immaturity. And so how do we Kristen West: help see if we can facilitate development of safe swallow and sucking and coordination that they should have been working on in utero. But you know they were born too early, and we're trying to help mimic that in the Nicu Kristen West: we also want to think about the family and family centered care. The family needs to be integrated into our care. We want to teach them how to have a healing environment that manages stress and pain for their infant. How do we offer calm in a soothing approach that involving an entire family, because that improves health, outcomes the length of stay and decrease costs are associated with that. Then in the Nicu from a cost perspective. And that's, you know, a healthcare utilization point that we need to think about as well Kristen West: again, the goal of Nicu interventions for us as an slp is protective. So we want to be protective and preventative in the ideal scenario therapies. Ptot speech are all present in the Nicu, and they're consulted with any baby who comes into the Nicu with a high risk of having, you know, feeding, swallowing, and other developmental challenges. Kristen West: That is the goal we'd be consulted, or an order from the medical team is given to us before a problem arises. It's not. We've been trying to feed this baby, who's 37 weeks now for a week or 2, and we've not had success. Can you come in and see what your thought is and fix it? We kind of want to be there from the onset and see the child's development and see if we can prevent problems. Kristen West: I do recognize this is not always the case. This is ideal, and this is what we consider best practice. But some nicus and some hospitals do still run on this. Let's wait for a problem to arise before we consult Slp. Kristen West: but that practice pattern is going away slowly but surely it is reducing. But there are real world barriers like staffing and cost and availability of specialist therapists that can help support in the Nicu. Kristen West: But the goal is that preventative? Hey? This baby was born at 27 weeks. Now they're 33 weeks. We're looking to feed them in the next couple of weeks hopefully. Why don't you come in and work with them? Why don't you also come in and see how they're responding to their environment. Start talking to the family, build rapport, and let's work together to figure out. You know what what the next step is. Kristen West: So much of how that infant responds is nonverbal communication via their color, the way that their face looks, you know their vital signs. So that's their oxygen, their heart rate, their respiratory rate, those kind of things. And we are experts in reading communication, including nonverbal communication. So we need to think about that. A lot of what we do in the Nicu is counseling, counseling the family, counseling the medical team and being a consultant there to kind of provide our insight. Kristen West: So that's something that we need to think about. Kristen West: Why, neuroproductive care. I think this is an interesting diagram. I blew it up so it does look a little distorted. But I still think this makes sense for us to look at this little line that I put here. Most infants are admitted like somewhere here, right? Not 24 would be a little early. Those are pretty extreme preterm infants, but somewhere here is where they are, the large bulk of our Nicu infants that are preterm. And look how much brain growth, like gyri and sulci and brain like Kristen West: development, is happening between 20 weeks, 35 weeks, and even between 35, and 40 weeks for our late preterm infants. And so there's so much of that. Kristen West: you know, finalization or refinement of that central nervous system in the brain that's happening during this time period that even like when we think about late term preterm infants. Right? There's so much brain growth that's still happening. We really need to be aware of that Kristen West: one thing that does happen, and is that you know in between before the 35th week. And in that 3rd trimester it's the end of neuronal migration. So neurons are migrating in the brain to be if they're a special neuron, right? If they're a vision neuron, if they're one that's going to be associated with like speech, right? That specialization of the neurological system, and those neurons happens, and they migrate to kind of where they're going to be. Kristen West: and that can be interrupted when that baby is born too early. And then, all of a sudden, that process is altered because they're doing that in an extra uterine environment. So that's something for us to think about. And then, during this time period as well, there's proliferation. So proliferation is the re. So if you think about proliferation like being prolific, like a prolific writer or somebody who writes a lot. Prolification is the Kristen West: phase where the neurons are just multiplying and getting more and more. So it's that exceptional neuronal growth is interrupted in the Nicu as well. So they're born during that time period that's happening in normal neonatal development. And now it's happening in this development that is not at all like what's happening in utero. And so we think about that from a neurological level, about how that can negatively impact our infants. Kristen West: And so that's why we want to do neuroprotective care. That's why we're trying to normalize the nicu environment, is it? Let's make it quiet. Let's make it warm. Let's give positive touch as much as possible. You know. Let's let them establish sleep and wake cycles because we're just trying to not interrupt those processes unless we have to for their health. Well, health, well-being, and survival. Kristen West: So just think about the neonatal sensory development here for a minute. I think this is important for us to think about in the context of those different you know, extremely preterm, like preterm, those kind of qualifiers moderately preterm, etc. Kristen West: So, you know, tactile system is developed between 7 and 18 weeks. So it is well developed by the time that most of our preterm infants are born. But there is negative input that we're giving heel sticks. Ivs, you know, central lines. Any sort of like tape, you know, touch diapers on their body that they're they're not used to having that input. They were floating in an intrauterine environment like this. And now they're like this, right? Kristen West: So in typical development, we're seeing between 14 and 16 weeks the vestibular system has developed. But how are we? They're still floating in utero kind of in this amniotic fluid sack right? When we handle a baby in the Nicu, and we're turning them over and sitting them up and laying them down and putting them on the sides. That is different input than floating in utero and amniotic fluid. Kristen West: So it's a different type of input that we're giving them. And we just need to be mindful of that, you know those quick movements that people might think about like. Let me quickly pick up the baby. That's that's a lot for them that's like a baby roller coaster. So we just need to think about it. Kristen West: Olfactory and gustatory. So smell and taste are very closely tied senses, you know, again, that's something that we see as early as 2012 to 14 weeks, but in the Nicu they may have breathing tubes in their mouth and tape right, and oxygen that's being blown up into their nose, or they're intubated. And so, you know, they might be getting, you know, like more of a chemically taste when their mouth is wiped out, or chemically smell like. If I put my hands into this isolate that you're seeing right here. These are handholds. Kristen West: and I open. Just say Kristen West: a alcohol swab, because I'm going to like, you know, clean something that's a different smell. It's a very chemical smell. If they throw up, they get that taste in their mouth they didn't have. They won't have any of that. They were still in utero, because they're getting fed through their umbilical cord right? So from the placenta Kristen West: auditory system is developing between 18 and 35 weeks. So everything in utero kind of sounds like charlie Brown's teacher. If any of you've ever watched the Charlie Brown show, so it's like Kristen West: and so, and they hear their mother's voice like from that internal perspective. But now in the Nicu, and you'll see this in what you guys are, gonna hear and and view at the end of the learning materials, alarms, and sounds. They might be on a Cpap machine that's like. Kristen West: or maybe if they're really sick, they're on an oscillator. So it's like, and it's like shaking them. It's helping clear material like fluid out of their lungs. By like shaking it out. But it's giving them a different input and a different sound. And it's right there inside with them, right? That is very different than that typical Kristen West: development in utero that you would see here in the visual system, right? It develops from 38 weeks to term. That's like, really where we start getting really good refinement usually. But now we've got different lights, bright lights, you know. Maybe they're getting. They have jaundice. So they're getting phototherapy. And so they're just getting stimulation of all these senses in ways that are atypical. And sometimes before that system is fully developed. Kristen West: So we just need to think about how that could alter their developmental trajectory. Kristen West: So one thing that we really talk about, and that lays the foundation of everything that we do for infant feeding. Is called synactive theory of development. So synactive theory of development is really the basis for how we think about infant communication. How do we understand the infant's behavior as communication? How do we understand the infant's body system because their body is constantly interacting with their environment. So something in that environment could change how their body is going to react. Kristen West: So he'll read about this. But he's kind of giving you a little bit of an overview. It's telling us that Kristen West: to get to this top level, which is self regulation. Where a baby can, you know. Kristen West: deal with maybe something, you know, an unpleasant feeling of hunger or starts feeling comfortable, and they can put their thumb in their mouth, or find a pacifier root and watch, and like self soothe. They have to have intact, intentional, or interaction. They have to be able to like, you know, as much as a baby. We would expect to be able to do that. Be able to have those skills just stability in this in this Kristen West: concentric circle. That's kind of the second from the outside. They have to be able to maintain their state, have a stable motor system and have a stable autonomic system. So you have to have stability here here and here to support attention and interaction skills which help support self regulation. So we're going to kind of talk about this bottom up. Kristen West: In terms of signs of stability versus signs of concern. So, starting at the very bottom kind of the base of the house if you think about it, or about innermost circle of the autonomic system, babies who are really having a hard time dealing with what's happening in their environment, or even what's happening in their own body, are going to show a stress in their autonomic system. It's kind of like, you know. The house falls down from the top the whole way to the to the bottom. It crashes down. Kristen West: This is kind of that basic level of stability that we're hoping to support. And if we don't have stability here, we we have a hard time getting stability at these higher levels. So we need to know not only this stress here, but also, how do we look and see if our interactions are helping? We want to look for stability. Kristen West: So signs of stress of an infant and their autonomic system are color. If they are pale or very bright red, or they're dusky. So like a gray gray look, like they look like pale like. If you've ever seen something like you've lost all the color to your face like that's an autonomic system instability in an adult. We see that same sign in infants. They can be modeled, which is kind of like patchy. If you don't know what that is, take a minute pause. Look up, Nicu modeled skin tone, and you'll be able to see a good example. Kristen West: and you can have modeling like just on their face, or just on their hands or their whole body. If that you see those kind of colors like pale or very red or dusky, those 2 kind of extremes, not just like a healthy pink. That is a sign of stress. We are wanting pink over their entire body. That is a positive sign Kristen West: in terms of their respiratory pattern or their breathing. You know typical infant breathing is 40 to 60 breaths per minute for some of our babies that are that have been very sick and very you know, and have a respiratory condition. Their normal breathing rate might exceed 60 breath per minute. It might be more like in the seventies or eighties. So it is important to know that Kristen West: child or that infant in their condition, and they are kind of normal baseline, so like if I go in and the baby's pink, and before I do anything with them I want to look at the Monitor. Kristen West: or like the vital monitor that has, like their heart rate and their respiratory rate in their in their room, and see what is their like breathing rate at sleep, or when they're up in their ha, you know, in their in their kind of calm Kristen West: it might be a little over 60, but in a term. Well, infant, it's 40 to 60 breaths per minute. So just a caveat for having to know the individual nature of your infant, because, like a baby who has bronchopulmonary dysplasia or Bpd. A very common respiratory condition in preterm infants. Their respiratory rate at Kristen West: stability might be a little higher Kristen West: but knowing that child's or the infant's individual vitals. We want to look and say, Oh, are they much higher now that I'm handling them trying to feed them? You know? What does that look like if they're uneven, or they're high or they're low, because if they're low, then they're going towards apnea and hypoxia, which is apnea cessation of breathing and hypoxia is like not enough oxygen. That's going to be a concern, right? So you can be breathing too fast like. Kristen West: And it's that's that's stress for them, or they're Kristen West: having that period of I'm not breathing at all. So if there's pauses of more than 2 seconds, or they're gasping, yawning, coughing. Those are all signs of stress, you know, really knowing their normal respiratory rate pattern, which is information interprofessionally, we get from the nurse or their chart and using that to figure out, are we way outside of their normal range? That's going to give us a good idea for the respiratory pattern? Kristen West: We also think about visceral signs or signs in their body system, their organs, if they have stable digestion, and you know we we are able to burp them, or they burp themselves, and if they're being tube fed, and they have, you know. Kristen West: consistent, wet, and dirty diapers, which again is in their chart, and the Nicu and conveyed by the nurses, and something that's talked about every day. That's what we're looking for. If they're regurgitating, they're throwing up. They have frequent hiccups. Hiccups are stress signs in infants, but can also indicate some trouble with digestion if they're gagging, even if they're not like eating by mouth. But they're getting tube feeds, and they're gagging all the time, or they have excessive, drooling Kristen West: diarrhea constipation. They're really gassy. That's telling us something's going on with their gi system, and there's instability there, and discomfort there. And so just think of it this way, like, if you've got a tummy ache or you've got food poisoning, or you've got a stomach bug. Kristen West: It's hard for you to like. Pay attention and do your job, or study or work, or whatever that thing is right, because you don't feel well. So it's the same thing for these infants, but they just have a lot of they have less resources to pull from because they're they're sick and they're not even sometimes at term yet, or if they are, they've had quite a road even if they're now, you know Kristen West: post if they've been around. They're born 24 weeks, say another, you know, 44 weeks, which is post term. They've still had usually quite a complicated course to get there. So it's hard for them to eat Kristen West: and do other tasks that we might be expecting of them if they're showing us signs of autonomic instability. Kristen West: So we need to be aware of that and take these as communication. That how do you know is maybe right. Now, this is what's happening inside their body, and it's not a good time to feed them, because they're uncomfortable. They're not rooting. They're not latching. They don't want their pacifier and so they're not interested in feeding. Or wow, they're reading really hard right now in their crib on their own. Kristen West: And something they just seem like they're stressed. They're in pain. Maybe not the right time to feed them right? That's kind of how we use this information. Maybe we've started to feed them because they did look stable. And then we're a couple of minutes in, and we start seeing color changes changes in their breathing pattern. All of a sudden they're like turning their head, or you know, you take the bottle out to give them a break, and they start gagging, or they're hiccuping. We need to kind of be aware of that. Kristen West: Some of you might be listening to me say hiccuping and thinking like, well, this term baby is they get hiccups all the time. And that's not a stress cue. Again, you're right. We're viewing hiccups and kind of the broader picture of like not just hiccups. But if there's other things going on. And also in the context of a preterm infant who is doing something a little different than a term infant. Kristen West: So hopefully, we've seen autonomic stability. And if we have autonomic stability, then we're going to kind of see motor stability. But we could also see motor instability and still have autonomic stability, because it's kind of like that next layer? Kristen West: So when we're reading a baby's communication in the Nicu we want to look for, do they have signs and symptoms of stress in their motor system. Can we intervene at this motor level? So we don't start seeing instability at the autonomic level like, can we catch them early, right? If we catch them earlier and stayed in motor? Maybe we won't see autonomic stress signs. We can kind of help them support them and prevent this kind of collapse down to having autonomic Kristen West: instability. Kristen West: But if we see autonomic stability, we have to kind of go there and see what we can do to support them there. Maybe they just need a break. Maybe they need a little bit of time. Maybe they need to be swaddled. Maybe they need a little bit of Kristen West: of extra time to get to where they need to be. So that's just something to be aware of. But we, before we see autonomic stability, we will usually see motor stability if it's kind of something that is collapsing during a feeding exchange, for example. So we need to kind of think, okay, what are motor stress signs that I might see that are likely going to come before autonomic stress signs. Kristen West: So motor stability what we're hoping to see. The baby's arms and legs are rounded and softly flexed like they probably have their hands up by their mouth so they can, like root, find their fingers latch and suck, because that would be a self-regulation skill. Kristen West: When they're moving around like they'll do their at and r like they look like like I'm moving my arms in my trunk and my face, and it's you know they're smooth movements. If they're jerky or they're flailly, or they're flailing around. And they're like all over the place like hyper rooting. And when they're just doing what I'm doing. If you're looking at me. That is instability. Kristen West: We are hoping to see them not have that. We are hoping to see them holding their hands to their faith, mousing and sucking on their hands and adjusting their postures, because if they have motor stability, we're usually able to help support them, to have some self regulation that if they start to get stressed Kristen West: in in this system like we're starting to get frantic. But then I start rooting, and I found my thumb and I start latching on it, or I'm sucking on the blanket. I'll start to then see these stress signs turn into stability signs. But for our kids that have had a lot that are born very preterm and have a lot of medical comorbidities. They may not be able to do that. We might be able to have to hold them, swaddle them, give them a pacifier, hold them chest to chest things like that to help them. Kristen West: If they are stressed, they may not be able to self regulate and use these behaviors to attain their own motor stability, so we might need to help them. Signs of stress in their tone and posture they might have flat limbs and body they may have like a wet noodle, right? They might arch their back or their neck. They're excessively like tucking their body and like like, think about how you kind of like double over in pain. It's those kind of signs, but we're going to see them in a teeny, tiny little baby Kristen West: state signs of symptoms of state stress, again, usually are gonna predate motor, although sometimes they come so quickly that there's overlap, and you can't catch them. Before. You know CC. State and motor, because this Kristen West: can change very quickly for our nicu infants. But what you normally see is that their states are not easily defined. So we're thinking about kids that, you know, we're going to start thinking about. Are they ready to feed like at. You know, we're setting that foundation for feeding. So maybe they're 32 weeks, 33 weeks. We're looking at 34 weeks is kind of this time of. Maybe they'll be ready to eat by then, or 35, 36. We're going to start feeding them breast or bottle. We should start seeing well-defined sleep and wake Kristen West: so they should be like deep sleep, and then start to arouse, and then come out of that and then be like active and alert, but you might see if they are stressed or they don't have good state system stability. They'll be like dead to the world and deep sleep, and then wake up and be all the way on that normal you know, stages of sleep and alertness scale that you saw on typical development be crying like Kristen West: crying and borderline inconsolable. And it's like I'm out like a like. And then I'm up and screaming. There's not that kind of transition between. So those States may not be easily defined, or they would rapidly change, like I told you. Kristen West: in a inappropriateness of state to time so it could be like it's time you were. It's time for you to feed, and you woke up to feed. And then all of a sudden you've like Kristen West: passed out like you're now back out in a deep sleep because you're so stressed out. You've shut down. If you've ever seen like a newborn that goes to like a really, really, really, really loud, like events, like a party a wedding out in a noisy restaurant. If you've ever like, had your infants do that. If your mom's or know people that have infants in your family, you're like that baby was just awake, not tired at all, literally just woke up from a nap, and we brought them here. And now they're back out. Kristen West: That's sometimes what we call shutdown, because they're putting themselves asleep to kind of cope because they're overstimulated. So that would be maybe they're stressed out right? They're going Kristen West: It's tuckering them out. It's a lot for them to process. So they're done. That's normal for infants to see that happening in term infants. But you would see that in the Nicu happening as well. They might have unpredictable cycles. So you don't see this, like, you know. Well defined sleep to wake. It's just like kind of sporadic. They're not ever getting in the deep sleep which you know can be a problem. Kristen West: and if they get overwhelmed by stimuli, they may just shut down. So that's kind of stress. What we're hoping to see is they have sleep and fully awake. That's clearly defined. And we see them slowly transition between those sleep and stages and awake stages that we've seen in those normal development slides. And they smoothly transition before this. You see, cues like, Oh, no, they're starting to get a little fussy, so you can intervene before they're screaming. It's not like we were dead sleep. And then we woke up and we screamed all of a sudden. This state! Kristen West: It makes sense. Oh, you know, you typically feed every 3 h. But you take a longer nap. And it was 4 h, so you woke up and you started to Kristen West: wake up, and you fuss really well and like, now you're like, I'm like pretty, you know, upset. I want to be fed because, yeah, that makes sense for you, right? Because you've gone longer. So you're pretty starving. For that infant. They start to develop like a routine and a schedule. They may not have that exactly in the Nicu, but there is some predictability. Kristen West: They're not usually overwhelmed by stimuli. And again you'll start to see some self-regulatory behaviors like if they start to get overwhelmed, they might root or latch, find ways to calm themselves again. That are again expected for a newborn Kristen West: more stress signs that you might see we haven't talked about just going again. Autonomic motor signs state. And then here's some stress cues that you'll see above in the intention and interaction stage as well. Kristen West: So if they are stressed and you're looking for those attention and interaction signs of stress you're going to see the infant will demonstrate. State will demonstrate stress signals. That's a tongue. Twister stress signals of the autonomic motor and state systems. So they're going to be like a combination of these. They may have trouble. They can't look Kristen West: like look and face you like. So they're like, I can't face you like. My head's like here. I'm looking at you, and I'm trying to do that while I'm eating. I'm not able to all of a sudden I'm gonna like close my eyes. Now, you have to kind of know the infant like. Are they just tired? Are they getting close to being full? And they're actually just transitioning to sleep. Or is this really like a Kristen West: we just started? And there's a lot I'm gonna like close my eyes when I'm eating, because it's hard to integrate all that information they might be able to like. Listen to talking and suck a bottom out same time. So you're talking to the baby, and they stop sucking. But you stop talking to them and they're able to start sucking again. They just might have trouble integrating all of that information. Kristen West: Self regulatory behaviors. What do we hope to see that? Hopefully, we're gonna start seeing once babies get closer to term. They're going to attempt to deal with stress and regain control of their body systems. So I feel uncomfortable. I'm gonna move a little bit. Okay. I'm fine. Now. I'm gonna you know. I feel good. They're in their hands to the mouth. They grasp things they're sucking. They're visually locking and like looking at you like they're staring at me. Look at their eyes. They're so cute right, and they're clasping their hands. Those are all things we're hoping to see Kristen West: just again. Another way to kind of look for stress, this organization for sustainability organization, and some self help queues that you're gonna start seeing. So this is, I'm trying to help myself. But, like hey, as you as the adult here, you need to intervene. So just another chart. Another resource for you. Kristen West: One thing to know in the Nicu we do not want to disturb sleep. So we'll wait until, like changing diapers changing where the pulse ox is on their feet like the cares that the nurses will do, and feeding. We try to cluster them so they're sleeping. They wake up. We're gonna they're gonna change their bottle or their Kristen West: their bottom. They'll change their diaper. They'll change like, if the possible is on the left foot. Now it's going to go on the right foot. If they have to do like a blood draw, or they have to do anything, they'll do it all in that time period hopefully feed them, and then let them kind of, you know, have some interaction while they're awake, and then hopefully, they transition into a nice long sleep again, and then rinse and repeat, because in the Nicu sleep equals growth and development and brain growth and development. And Kristen West: you know that ability to just kind of help support them, especially if they are preterm like they're not even 40 weeks yet, because again, they're not supposed to be here. Kristen West: We are looking to help support brain growth during that deep, quiet, non-rem sleep. When we look at the States when we're looking for feeding, optimal feeding is quiet, alert. It's okay to do it in drowsy, you know. We'll start seeing quiet, alert when the baby's feeding as they get closer to the end. They might, in getting full or a little bit tired, because feeding can be challenging for these infants. They'll go to drowsy, but we really don't want to feed them when they're in these states. That's not ideal. Kristen West: So this is optimal for interaction, including non-nutritive sucking. So it's like pacifier sucking nns and feeding. Kristen West: If they're crying. They're stressed and overstimulated. And you know, do you think about what we do with a typical infant? We pick them up, we hold them. We try to shush them. We do the same in the Nicu, but we try not to get babies to the state in the Nicu, if we can avoid it, because it burns a lot of calories and a lot of energy. And again, everything they do is just harder. So we're trying not to have them be in this state for a while, because if they are, then it can lead Kristen West: to that kind of Kristen West: you know, collapse here where they're they could get some instability like heart rate, breathing oxygenation and stuff. So we try to intervene. Kristen West: So that's an active theory. You'll have more readings on it. But that's kind of an overview and things to know. Now we're gonna please do do the readings, by the way, because I cannot cover all of it here in a lecture. And I can give you the overviews of it. But I do want you to spend a little bit more deep time on that, so please do take a peek of that, please. Also. Do take a peek. And of the other videos that you have at the end of this module. That helps kind of support your understanding of of these concepts. Because, again. Kristen West: they're really important in there to help support your learning. Kristen West: So let's just take a transition. Now, synactive theory is what we're going to use to judge feeding. You know, what looks, what stress and feeding, how do we respond? What changes do we make? That's a framework we're going to use moving forward. So please make sure you understand that you do your readings post any questions you might have Kristen West: also want to talk about neonatal and integrative developmental care model. This is used in the Nicu by the interprofessional team. Kristen West: So the nicu integrative developmental care model. It's by Altmire at all. What you will see is it's this Kristen West: it's visual, and how it's presented is the 6 lotus flower petals in a center are the core measures. Okay? So what you have is you're trying to make a healing environment via touch, smell, taste, sound and light. That's all positive that are in that neurodevelopmental care that we talked about right supporting that positive normalizing the experience. We get that by partnering with families, making sure we optimize nutrition. That doesn't necessarily mean all by mouth that can be via a tube feeding as well. So in through their nose. Kristen West: or sometimes even in through a tube in their mouth, depending on how preterm they are and what's going on. We want to protect their skin, so we don't want them to have skin breakdown, you know. So like even just thinking about diaper rashes and sores and things like that, we need to protect their skin. Their skin is more friable when they're born preterm, it's not as thick, it's thinner. So we need to think about that. It's kind of akin to what you think about in the elderly. When their skin becomes more frail. Kristen West: We want to minimize their stress and pain like I've talked about. We want to safeguard sleep, which we've already talked about, and think about how we position and handle the infants as well. Kristen West: It really outlines what the whole Nicu care team is focusing on, not just medical outcomes. Our services are aimed to support all of this because we are really Kristen West: everything we're doing is tied to reduce negative effects of the stay in the Nicu or protecting their neurological development. And we want to help support them, to develop those developmental skills along that expected continuum or as close to that as possible. While still maintaining an air of positivity and positive experiences for the infant. Kristen West: So the healing environment. One thing to think about Kristen West: we know from research that in the Nicu infants have improved outcomes on environmental stress. So sound, light, touch, temperature proprioceptive. So how they're, you know, picked up and handled taste and smell. That is caused by like Kristen West: when environmental stress, which is caused by overstimulation, is reduced. So if we think about all of those things and reduce them. Then they have improved developmental outcomes. We also focus on the family's presence or reunification. So we talked about, how do we get the family to the bedside. How do we support them? To be present with their infant? That's reunification, that's positive. Family experiences. Kristen West: How do we limit extraneous sound light smell. How we have them in a single room setup, but not isolation is usually some of what we talk about versus a pod, where they're all kind of in a room together. So there's kind of this debate like they need Kristen West: to have some quiet and families feel best supported when they can have, you know, a space with their infant on their own. We also, if that family is not there all the time, don't want the infant isolated and never interacted with. Kristen West: So you'll kind of see here in the top there's carpet on the floors. You know. There's not a door on this room. It's just a curtain. So you know, we're trying to keep some of the sound out. There is the ability for the infant be by themselves, with their family. But the family is not there. Obviously, then, you know, these nursing stations are right here so they can get that interaction. Kristen West: In the room. There's, you know, chairs, maybe couches, beds that the family can sleep in lights that are you kind of see them redirected up here so we can turn the overhead lights off and have them redirected. So they're not just over the the crib of the infant, for example. Kristen West: So those are all healing environment things we think about. They may cycle the lights on during the day and off at night. They might use eye covers over the baby's eyes, or they might put something over on the isolate, or like the incubator like here, that the baby's in it might be covered to kind of, you know. Keep those lights off. We know if we cycle the lights and kind of stimulate day and night we have improved weight, gain shorter stays and increase. O 2 levels or oxygenation levels of the infant. Kristen West: Also we know that this is decreased. What rop is is retinopathy of prematurity, which is a diagnosis, an eye complication for infants which can, in fact, impact their vision negatively. So we have decreased instances of that complication of retinopathy, of prematurity with cycled lighting and better growth. Kristen West: We think about sound reduction. The sound levels in a Nicu can range from 7 dB. To 120 dB. Which exceeds the Max, and often exceeds the maximum level of 45 dB. Or decibels, which is recommended by the American Academy of Pediatrics. So we think about, how do we reduce that? Some of that is like carpeting sounds from the hallway? Maybe doors in the Nicu even to kind of soundproof a little bit. Kristen West: We really think Kristen West: really want to just think about that happening. Because we know on the next bullet, Hl, hearing loss is increased in premature infants from like 2 to 10% in comparison to the normal infant population. Kristen West: So things like quiet times with the light, or like noise, reduction, or like visiting hours. That's kind of tied to that. They also think about decreasing the alarm volume. So maybe the alarms are gonna ring out into the nurses phone or to the nursing station instead of right there next to the infant's bed, or if they do, their Kristen West: lesser dB in the room, and and louder in the other space floors that absorb the sound. If the isolates and incubators are of a higher quality that they can filter out the noise. Putting rubber wheels on the cart, we talked about clustering care how you do all the things that we need to touch. The infant at one time. That also limits the amount of people walking in and out of the room repeatedly. Multiple times, putting a lot of like just noise. That's coming in through the floor. Those kind of things we also think about smell and taste. Kristen West: So oral colostrum care. Colostrum is the 1st drips of breast milk that come after an infant is born. It's really like nutrient dense has a lot of positives. So instead of wiping their mouth out with some sort of like swab or water. We can use that, and that's a more positive smell and taste, and it also has a lot of immune benefits. Kristen West: We want to think about limiting procedural smell. So I gave the example of like opening up something like an alcohol. Rub in that isolette with the infant. So now they're like stuck smelling it. Kristen West: We really need to think about that. Sts is skin to skin. So, putting the baby bare except for, like a diaper on the bare skin of the chest of the mother, the father, the family member, with like a blanket over them that really can help them because they smell their mom. They smell their loved ones. That is, that familiar smell really good for breastfeeding, breastfeeding Kristen West: parents as well, because it helps with milk supply, so you can kind of do that. And then they might put a little piece of that cloth or a little heart that maybe it's been worn inside the parents like clothing in with them. So they smell their family. But we don't want to have a lot of adult smells that are like lotions aftershave perfumes, because that can be negative for the infant as well. It's not natural. Kristen West: So these are just some things that we think about that are healing environment, and things we might see in the nicu A radiant warmer is something that you normally see in like a delivery room. These are different type of draft beds and isolates. So babies that can't maintain their temperature are going to be in here for a while until they transition to a more we call an open crib. So just a regular crib Kristen West: with side rails. These are billy lights or phototherapy. So if the baby's jaundiced, that's what they'll wear. These are the little eye covers. So sleep night. We might use them. They're also very commonly, almost solely. The only thing we see on an infant when they're in Billy light phototherapy because we need to protect their eyes. Kristen West: And this is an example of all the ideal aspects of a healing environment. Indirect. Overhead, light room, darkening shades, a folding couch that helps support reunification, a parent's closet specifically for the parents stuff so they can keep it over here a refrigerator in the room so they can stay and eat with the baby a rocker or recliner. So think about like skin to skin. They can just like rock and recline and stay there. Kristen West: The floors. They're not carpeted, but they're sound deadening. So underneath the wood. There's like, you know, absorbing for the air Kristen West: redirected monitor. Alarms aren't buzzing right here. They're redirected into the hall. There's a parent desk back here, so if they have to work, they could work there right and on that single room that allows them to be there all the time. So those are some of those ideal things that you might see. Kristen West: We want to support our families. It's essential to optimize developmental outcomes. Think about trauma informed care. So the Nicu is traumatic. Their psychosocial supports needed for those families. Kristen West: infants are also in in a state of fight or flight. There's just a number of threats to them. It's not like their caregivers are threats, but there's constantly some sort of instability there. They are fighting for their lives in some degree. And so they have that disrupted establishment of nurturing and secure parental relationships because they're thrust in. And then they don't have all that like I'm gonna hold you and love you and kiss you and and bond with you. They're they're thrust into this different environment. Kristen West: so that alters the relationship or the social interaction of the infant and caregiver for better, for worse. It just does. It's not what somebody wants to happen. It just is because our our really focus is Kristen West: getting this baby well and stable enough. And so, you know, we try to offset that as best we can. Early family stress can impact that child's behavior long term especially if we don't get families support. They need to deal with the trauma of being in the nicu you know, there is post-traumatic stress disorder associated with having an infant in the in the Nicu. Kristen West: so we need to give shared attention to the infant, but also their parent, and make sure that they have opportunities to do skin to skin, chest, to chest, hold their baby. Even if they're very sick. There's actually a lot of research that supports skin to skin. Putting the baby on the chest Kristen West: with the parents can help be something that positively impacts, you know, before they're closer to term or before they're 34 weeks, and we're feeding them. Something that helps stabilize their vital signs. So their heart rate, their breathing rate. Those kind of things. They have less autonomic instability when they are chest to chest and in bare skin the bare skin with a caregiver. Kristen West: So it's something we see used a lot in the Nicu with really infants that are really sick. It's not something that we necessarily use to say support an infant during feeding, because unless they're trying to breastfeed. Then maybe we might use it, as it's just like another positive that occurs. But we see it as a as a really good bonding tool that helps support stability before feeding Kristen West: even immediately, right before feeding for their 1st couple feeding attempts, but also thinking about it as just like a normal thing that we want to include for the family and the infant in the Nicu. Kristen West: We want to aim for reunification and 0 separation between the infant and the family. So they get that secure attachment and emotional connection, so that skin to skin sts, or sometimes called kangaroo care is really research supported to help that maternal responsiveness. So they feel like bonded to. Their baby, also helps with milk supply for breastfeeding infant then gets that attachment to their caregiver, and it's really got improved developmental outcomes and brain development. Kristen West: If there's limited quality or quantity of parental care. You know, if they're scared or they're nervous and not supported. It does just. Kristen West: And it's really, significantly. So there's negative changes in the brain structure and function from what we know from like developmental outcomes. So we just want to really think about that Kristen West: proper positioning in the Nicu is important. What I showed you way back here on this slide. I'm just gonna go back there for a minute. Kristen West: Do to this. This is not for appropriate positioning in the nicu ideally there's a lot going on with that infant. Kristen West: We want to see the infant look more like this. So oops keep coming. Kristen West: You know they might be in these little snuggle rooms, they might be on their side. This baby's intubated. So that's why they're on their belly that can also help with breathing. So we don't put babies to sleep on their tummy in any situation here, but this baby is intubated laying on their stomach can help reduce pressure on their lungs, so we see them in this way, but they're still well supported. They have boundaries Kristen West: think about in utero. When they stretch, they hit the uterine walls, and they come back in. And now, all of a sudden, they're not there, and and there's no boundaries. So we need to create those boundaries that help develop that appropriate muscle tone, and and kind of Kristen West: reinvent that experience that they have in utero. So you kind of see. Kristen West: not happening here with these positioning aids that they're using, and then you also will see here that you have an infant that has a mother's hand on their head and then on their bottom here that's sometimes called a hand hug. And so this baby's got, you know. They're on their side. They're in this little snuggle room. They're wrapped up so they stretch, they can move. They're not like so tight, but they give it that little bit of bounce back. Their shoulders are rounded, their hips and knees are flexed, the toes are pointed straight, they can bring Kristen West: hands to their mouth. So you see, hands to mouth here and hands to mouth. Here again. You're not going to get hands to mouth on this infant, but they're intubated because they're pretty sick. Kristen West: So you know, if they're able to. We want their hands to their mouth. We don't really want their hands to their mouth if they're intubated, because they're going to pull that tube out. We want those boundaries to be provided. So you've got those good boundaries and their eyes, knees and toes kind of all going in the same direction. Kristen West: Proper handling. They can feel that effect of their vestibular movement when they're quickly turned. So if we turn them like, here's my hands. I'm moving up and down and all around. You know. So if we are like quickly flipping them around like, here's their head, and I just brought it forward, and I'm laying them back down. I'm putting them on their side. That's uncomfortable, and that can make them feel sick. Sometimes it's called those quick turns which is sometimes known as a preemie flip has been saved to cause disorganization and the infant system modulation so like state. Kristen West: and even like motor state, and even sometimes physiological stability for up to 20 min. Because it's just so jarring. So we want to do smooth, slow, modulated movement. So I'm coming in. I'm going to hold the baby, and then I'm gonna slowly hold them up, and I'm gonna slowly transition them to me. So I don't do something like I'm laying flat and all of a sudden I've been sat straight up Kristen West: right? We think about like I don't want to touch them that much like. So we're just gonna do like a light touch, because we're like scared to hurt them or break them. But think about light touches like a tickle, right? So light touch or gentle stroking can seem over stimulating or irritating, because it's like tickle, tickle, tickle, like. And you know, that's like really alerting. So we want to do. Gentle but firm static containment. You kind of see this with the hands here. Kristen West: Or those hand hugs. This is a baby that's actually here getting what's called a swaddle bath. So they're giving that firm pressure during a bath. So the baby's rooting, trying to, you know, control themselves. Kristen West: To be nice and calm. This baby is not liking their bath. Obviously. So they're screaming, and they're yelling, which is a term baby. So it's fine. But that's going to lead to motor and physiological instability in our in some of our babies, who are, you know, not quite 34 weeks, or have a lot of medical complexity. So we're kind of thinking, for how do we keep them? Kristen West: Handled and kind of more calm like these top 2 Kristen West: touch. We want the touch to be positive. At the top. You see a lot of examples of negative touch. They have pick lines, they have peripheral, intravenous access which is normally going to be on their heads, because that's where the biggest veins are going to be. If they aren't intubated like you've already seen, there's an Og tube in this infant's mouth right here, where my cursor is. This is called a nasal cpap, so there's something on their nose that's helping to give that positive pressure into their airway. And then this is the apparatus that's securing it to their head. So there's a lot of negative touch. Kristen West: I want to counteract that with positive touch. Those hand hugs. There's a protocol called infant. So you see that here this protocol called infant massage, which is a positive kind of that deep pressure, but not like really firm either, but just, you know. Kristen West: kind of calming, organizing touch. That's a protocol that might be used. This is skin to skin kangaroo care. Kristen West: because we know negative touch can do. Hypoxia bradycardia, which is low heart rate, sleep, disruptions, increased intracranial pressure, and those repeated episodes of hypoxia and increased intracial pressure can place preterm infants at risk for things like Ibh and other neurodevelopmental delays and things like oral aversion or sensory processing disorders and differences later. So we always want to think about getting positive touch to offset these negative procedural touches that we see here. Kristen West: And this is just an example of kangaroo care Kristen West: again, which we talked about, and it can really help support physiological stability, more deep sleep, which is healing. If there's been a brain injury or brain growth associated with that, it helps them have more weight gain. It helps their heart rate. Breathing and body temperature be better regulated. If it's the mom that's doing it. It can help with their milk production, and it promotes bonding. This baby's intubated and is in skin to skin. This baby is just on, you know. Kristen West: a nasal cannula through their nose. But they kind of have their onesie unbuttoned in the front. And so it's over them, and the mom's got like a fleecy zip up, and she's able to to wear that over the infant. This is kind of a wrap that the woman is wearing over the baby who's on chest skin. The skin doesn't have to be the mom. You can see this. There's a male caregiver that's doing it here as well. So it's really just that skin, and they have a naked baby, a bare chest, and then, you know, a blanket, so it can be done that way as well. Kristen West: Optimizing nutrition is the next one. It's not just oral feeding, but also tube feedings and consider things like non-nutritive sucking or pacifier during tube feeding if they like to suck on a pacifier while they're getting an Ng tube feed that's like through their nose, and their mouth is open and we can give them a pacifier. They kind of link and learn sucking and belly full, even if they're not appropriate to feed by mouth. Yet Kristen West: oral colostrum care like, I said, cleaning their mouth with those 1st strips of breast milk instead of using something that's more like water or something else is important, and anything that's like positive oral experiences like working with the pacifier which we'll talk about, an assessment can help support. That positive transition to optimizing their oral nutrition. When we get there. Kristen West: We wanna talk about supporting practices that facilitate we call infant driven so like the baby's the boss, and we're letting them tell much how much they're gonna eat when they're gonna eat and when they're done, and we'll talk about what that is. Kristen West: That's called responsive feeding practices. So we're not going to force them like, oh, you need to eat 2 ounces. If you get e 2 ounces, you'll get your tube out. Let's just push you through. No, we're going to encourage them. But we're not going to force, because we know that the research tells us that being responsive and using synactive theory to guide how we start and how we end is best supported for success, long term, and short term for our infants. Kristen West: This is a support family and their feeding goals. So if the moms, you know, and family and caregivers say, I really want to breastfeed, that's great. We want to help support them, to obtain that goal. But it's okay, if that is not their goal as well. And so we need to do that. Family centered care. Kristen West: Research tells us that Ebm, which is express breast milk. So think pump, breast milk into a bottle, and then given via an Ng tube. That's what's tolerated best. So even in the Nicu they'll use things like donor express breast milk to help, because it's easier for the baby's stomach to digest it, and it's easier on their system. It has decreased necrotizing. Enter colitis, which is a really significant medical complication related to the death of the gut or the intestines Kristen West: related to the infant's prematurity in demand of digestion Kristen West: which can then cause sepsis. So we know that if we are giving babies express breast smoke instead of formula before their term before they're 40 weeks in the Nicu literature. It tells us this is reducing their risk of neck and sepsis. It also reduces the risk of retinopathy, of prematurity as well. Kristen West: So just kind of a shout out to that. That's why we try to support families. To pump and then get that via tube feeding, even if the baby can't eat from a breast or bottle. But again, if the family can't or they're not able to, because again, the Nicu is very stressful. We support that family in their decision and then look to donor milk that's been screened through like a breast. Milk bank is usually the route that happens in the nicu Kristen West: what we see long term. If they use express breast milk in the nicu, there's deeper green matter, brain volume, better IQ and better neurodevelocal outcomes that we see in the literature. It doesn't mean it has to be that mom's breast milk. It's just breast milk in general that's supporting them through that growth that's happening in an extra uterine environment. So again, we're talking like before they get to term. Kristen West: and we want to do infant driven feeding. So it's responsive feeding by the Slp, the family members and all members of the team. So we'll want to look for cues for feeding, readiness and family support, and then, you know, recognize that that baby's behavior and tolerance of feeding may change over time as they get more tired as their body starts digesting food, reading for those cues and adjusting accordingly, which we'll talk about in future lectures. Kristen West: So those physiological and behavioral cues of stress that we talked about in synactive theory. Kristen West: They are how these babies communicate for us. So we want to be responsive to that. So you have to know the stress cues. So just a plug here know what stress looks like in those different levels and know what stability looks like. That is the foundation for reading, infant feeding, Nicu, and otherwise. So you need to be aware of that. Please take time to commit that to memory. Kristen West: The takeaway points for us in the Nicu is, it's not just feeding and dysphagia communication happens all the time. We facilitate responsive interactions. Interprofessional practice is best. Your role may be interdisciplinary or transdisciplinary, depending on the setup of the Nicu. So just know that those terms aren't familiar with. You should have been covered in some of the clinical classes or some of your leveling coursework, so make sure to look those up. Kristen West: But the biggest key here is that, you know. Collaborate. So when the medical rounds are happening, when the you know the nurses and the doctors are going around in the morning and talking about how the patients are doing. See if you can participate in those as the Slp. Provide that information, or at least send your information off to somebody to make sure it's Kristen West: given and it's written away in the chart that it gets shared. Kristen West: Thinking about that environment set up, you know, if they're going to restructure the Nicu. We might be part of that team that helps give input on that. Thinking about, you know, procedures like advocating and working with the interprofessional team to get standing orders. You know any baby that was born before 37 weeks gets an order for speech that we come and take a look at them at 32 weeks, so we can help support them getting ready to feed by mouth. Kristen West: We really just need to look at that infant holistically versus just siloed like understanding their medical psychosocial. You know, where's the family? What's the family at that family centered care when we're looking at? How best to support that infant, not only in the Nicu, but when we set them up to go home. Kristen West: we want to prevent and reduce the impact on the Nicu stay on the infant's long term development. Sometimes we are viewed in neonatal therapy as being the brain protector, and we're trying to normalize the experiences, so help make sure that simulate the womb outside of the womb, offset all the medical stuff that's happening with things that are positive. So we can normalize that neural pruning. And you know, neurons that fire together wire together system that's being established. Kristen West: We also have to remember that it's not just about the baby. It's about the family. They're your patient as well. They're an important team member. So we have to make sure that once we are working with them to help understand their infants feeding and behavior, and we're teaching them how to read their baby's cues and how to support their infants, feeding and overall development. Kristen West: So with that that ends our lecture here. And so we will be taking this kind of in 3 parts. So this is part one. Please make it make a point to go ahead and read and view all the videos that are in the module, and let me know if you have any questions, or if you have any concerns.